Healthcare Provider Details

I. General information

NPI: 1821150426
Provider Name (Legal Business Name): KATHALEEN L THOMAS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATHALEEN L SMITH FNP

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60205 BODNAR BLVD
MISHAWAKA IN
46544-9342
US

IV. Provider business mailing address

350 COMMERCE SQ
MICHIGAN CITY IN
46360-3376
US

V. Phone/Fax

Practice location:
  • Phone: 574-345-0246
  • Fax: 574-381-5740
Mailing address:
  • Phone: 219-872-9158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28127434A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: